Healthcare Provider Details

I. General information

NPI: 1154197614
Provider Name (Legal Business Name): KALISPEL TRIBE OF INDIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10811 WEST 6TH AVENUE
AIRWAY HEIGHTS WA
99001
US

IV. Provider business mailing address

1887 WHITNEY MESA DR # 8844
HENDERSON NV
89014-2069
US

V. Phone/Fax

Practice location:
  • Phone: 509-514-6713
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA KOOT
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 209-403-5977